Transfusion for anemia w/o active bleeding in ICU pts:

838 ICU pts w/o active bleeding and Hb < 9.1g/dl randomized to "restrictive" transfusion strategy (transfuse when Hb < 7, maintain in 7-9 range) vs. "liberal" strategy (transuse when Hb < 10, maintain 10-12); restrictive group had nonsig. lower 30d mortality rate and sig. lower in-hospital mortality rate and sig.lower rates of MI and pulmonary edema while in ICU (NEJM 340:409, 1999--JW)

In a prospective observational study of several thousand ICU patients, receipt of transfusion was ass'd with sig. higher in-ICU mortality (OR 1.37) after adjustment for various measures of severity of illness (JAMA 288:1499, 2002--JW)

Transfusion reactions:

I. Clinical features

  1. 20% incidence of some sx
  2. Sx: fever, chills, urticaria, lymphadenopathy, joint pain, hypotension, bronchspasm, Hemolysis, disseminated intravascular coagulation (DIC).
  3. Fever results from contamination, destruction of transfused WBCs, hemolysis--more likely if not patients? 1st transfusion
  4. Urticaria 1-3% incidence, mostly in atopic pts, may be associated with anaphylaxis/hemolysis
  5. Acute hemolysis us. results from ABO incompatibility. Get high fvr, n/v, htn, back pain, hematuria, confusion. *Can occur 5-10d post-transfusion*
  6. Citrate toxicity (citrate added as preservative)--tetany, vascular collapse--UNUSUAL
  7. Mismatched blood causes intra- and extravascular hemolysis, ischemia, bleeding, anti-IgA Ab rxn
  8. Can get passive sensitivity from an atopic donor
  9. Leukoagglutination can cause acute pulmonary edema
  10. GVH if get donor WBC; more likely in neonates & immunosuppressed; not poss with irradiated blood

II. Treatment for transfusion reaction

  1. Stop transfusion! unless just urticaria, mild fever
  2. Check blood labels, call blood bank
  3. Monitor BP & urine output
  4. Labs: free Hb in serum & urine, bili, methemoglobin, BUN/Cr, PT/PTT (all can be increased if hemolytic)
  5. Give IVF and, if hypotensive, pressor amines
  6. If febrile, give antipyretics
  7. If urticaric/other allergic rxn, give diphenhydramine 1.25mg/kg IV
  8. If anaphylactic, EPI 1:100 0.2-0.4ml IM, also IV antihistamines
  9. If moderately hemolytic, give LASIX to boost urine production and once pissing, alkalinize urine
  10. If severely hemolytic, give MANNITOL 0.3g/kg in 20%IV over 15min, also plasma expanders and Solucortef. Plasmapheresis can be used to remove Ab's
  11. If citrate toxic, give CaCl or CaGluconate IV--SLOWLY